Despite Panel`s Recommendation, Cataract Guidelines Still Cloudy

In the current climate of health-care cost-cutting, the recent release of guidelines on when and why to have cataract surgery have confused and worried patients and some doctors.

An independent panel convened by a federal agency, the Agency for Health Care Policy and Research, came out last month with a recommendation that a patient with a cataract should consider options other than surgery -- namely wearing glasses or using other visual aids.

A cataract, a cloudiness in the lens of the eye, is most commonly caused by advancing age. It eventually can lead to blindness; in fact, cataracts account for 50 percent of blindness worldwide. The only treatment is surgery, which has a success rate of about 95 percent and usually can be done on an outpatient basis.

However, it`s not unusual for a cataract to take 10 years or more to develop to the point where it is seriously impairing a person`s vision, and glasses often can compensate in the meantime.

``If you look at the population over 70, 60 to 70 percent will have a cataract, but some will never get worse,`` said Dr. Robert Cykiert, assistant clinical professor of ophthalmology at New York University Medical Center. ``They can last like that forever.``

Because of this, the panel said that surgery is necessary only if there are other diseases in the eye or if the cataract is interfering with the patient`s life. And the panel questioned the routine use of certain diagnostic tests, because it said there`s not enough scientific evidence to show they are useful.

Does this mean -- as some elderly people fear -- that Medicare soon won`t be covering cataract surgery -- the most common surgery for people over 65, which costs Medicare about $3.4 billion a year?

Not according to the doctors on the panel and such groups as the American Academy of Ophthalmology, which endorsed the guidelines. They say the guidelines should be seen only as a way to educate patients about the full range of possibilities before they opt for surgery. A good doctor should be doing that anyway, said ophthalmologists interviewed.

``We tried to stand in a patient`s shoes and ask the question, `How should I make a choice?` `` said Dr. Denis O`Day, chairman of the panel and head of ophthalmology at Vanderbilt University Medical Center in Nashville, Tenn.

O`Day said he would ``fight all the way`` any attempt by the government to use the guidelines as a way to deny Medicare coverage for patients who want and need cataract surgery.

The guidelines say a patient should not have cataract surgery if: (1) he or she doesn`t want it, (2) glasses or other visual aids are satisfactory, (3) the patient`s lifestyle is not compromised, (4) the patient is too ill to undergo surgery.

More complicated and controversial is the panel`s refusal to endorse some diagnostic tests that check for certain kinds of visual loss from cataracts. These include contrast sensitivity testing, which measures how much a person can tell contrast between objects, and glare testing. Cataracts can make it hard for a person to see in sunlight or to drive at night because of glare from oncoming cars, although they may see reasonably well indoors.

O`Day, who said he rarely uses these tests, said the data on whether they are effective tools for recommending surgery is simply not there.

But the American Society of Cataract and Refractive Surgery refused to endorse the panel guidelines because they ``don`t reflect state-of-the-art technology,`` said David Karcher, executive director of the society.

For a copy of the guidelines, write to the Agency for Health Care Policy and Research, Publications Clearinghouse, P.O. Box 8547, Silver Spring, Md. 20907.

For more information on cataracts, contact the American Academy of Ophthalmology, P.O. Box 7424, San Francisco, Calif. 94120-7424; or the National Eye Institute, National Institutes of Health, Bethesda, Md. 20892.